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Package advice in practice - Deliberations for arriving at a fair package

The public debate pays a lot of attention to how we can continue to pay for health care in the future. A question that the Zorginstituut feels is equally important is whether health care, and the available funding, is shared fairly. After all, all citizens aged eighteen years and older contribute to the basic insurance and it is important that they remain willing to make this contribution. Insight into the evaluation process and the criteria for reimbursing care helps to guarantee this solidarity. Zorginstituut Nederland has written this report to provide insight into how this works in practice.

Relevant and fair

This report is a follow-up to the report on Cost-Effectiveness in Practice that the Zorginstituut issued in June 2015. In that report we explained why we regard cost-effectiveness as a relevant and fair criterion, though opinions in society differ on this matter. In addition, we explained how the Zorginstituut evaluates the cost-effectiveness of care. Unfavourable cost-effectiveness does not automatically result in negative advice, and favourable cost-effectiveness does not always result in positive advice. Whether we accept an unfavourable cost-effectiveness depends on other compelling arguments.

Conflicting values

In this report, the Zorginstituut shows which arguments can lead to us advising the Minister to reimburse a therapy or provision that has an unfavourable cost-effectiveness. These arguments can generally be traced back to package criteria, though this is not always the case. Arguments are often specific for a given situation.
This report cites examples illustrating how values can conflict with one another. In such cases it is important to determine which argument carries most weight. The fact that interventions sometimes get included in the basic package and then removed again on numerous occasions shows that such an evaluation may change over time.

Not an automatic process

In other words, arriving at package advice is not an automatic process with a predictable outcome, even though the criteria are known in advance. This is why the process demands so much attention. The Zorginstituut follows the principles of the ethnical framework of Daniels and Sabin (Accountability for Reasonableness, often abbreviated to A4R). This means that we make use of a so-called deliberative process, whereby all parties make a contribution, e.g., parties in health care, the Zorginstituut and its advisory committees. This interactive process results in us giving the Minister well-balanced advice about whether or not to reimburse care from the basic insurance.

Room for new arguments

Examples are given to show the underlying values of package criteria and other arguments, and how social values can conflict with one another. It is important that the process always allows room for new arguments. It would be impossible to provide an exhaustive summary of all criteria and arguments that can play a role in package advice. This is because new arguments can always emerge. What’s more, the importance that society attaches to certain arguments may change over time. The basis of this balancing process is, however, constant: the application of criteria in a process of deliberative and interactive policy.